Provider Demographics
NPI:1699353169
Name:DESHON NELSON, NICOLE MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:DESHON NELSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:DESHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:25 CLEVELAND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2935
Mailing Address - Country:US
Mailing Address - Phone:276-638-8888
Mailing Address - Fax:
Practice Address - Street 1:25 CLEVELAND AVE STE E
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2935
Practice Address - Country:US
Practice Address - Phone:276-638-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014142651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty